Suneeta Krishnan, PhD Women’s Global Health Imperative RTI International, USA/India

1. Moving From Research to Practice: A Multi-level Response to Intimate Partner Violence in Urban India Suneeta Krishnan, PhD Women’s Global Health Imperative RTI International, USA/India Epidemiology and Statistics Unit St. John’s Research Institute, Bangalore

2. Presentation Aims • Insights from Research: Prevalence and triggers of intimate partner violence (IPV) among young married women in urban low income communities in India. • Moving to Practice: A multi-level response to IPV in an Indian municipality.

3. Intimate Partner Violence Defined • Actual or threatened physical, psychological, or sexual abuse of women perpetrated by intimate partners • Physical: beating, kicking, assaults with a weapon, homicide • Sexual: coercive sex, unwanted touching, sex without protection despite requests, forced engagement in humiliating/degrading actions • Psychological: belittling, threatening, restricting mobility and social contact, withholding resource

4. Costs of IPV • Direct costs: adverse health outcomes, expenditure on and value of services used • Poorer health outcomes among women and children: non-fatal and fatal • Greater health care utilization leading to economic costs to the individual, family, employer, and society • As high as 75% of a family’s average weekly income • Indirect costs: lost earnings and productivity • Time off from paid or unpaid work • Lower productivity • In Bangladesh, estimated average value of lost work per incident of violence was $5. Source: International Center for Research on Women (ICRW). Intimate partner violence: High costs to households and communities. Washington, D.C.: ICRW; 2009.

5. Context: Indian Women’s Experience of IPV • Total population > 1.2 billion • Average age at marriage for women: 17 y • Prevalence of physical, psychological or sexual IPV among women of reproductive age (15-44 y): 40% (nationally representative estimate) Source: National Family Health Survey II, 2005-2006

6. Research Goals • To characterize the impact of gender inequities on young women’s health, including the prevalence and triggers of IPV*. • To assess the feasibility and effectiveness of potential interventions aimed at preventing IPV and promoting women’s health. * Data in this presentation focus on physical violence.

7. Setting: Bangalore City, Karnataka State • “Silicon Valley of India” • City of 9 million • Fastest growing metropolis in India • Third highest number of “high net worth individuals” • Construction boom and high demand for domestic workers

8. Setting: Slums • About 1 in 5 reside in low income neighborhoods or slums • Women employed as domestic workers, construction laborers, garment factory workers

9. Phase 1: Develop measures of gender inequities and IPV Phase 2: Identify impact of gender inequities including prevalence and triggers of IPV Phase 3: Examine feasibility and acceptability of interventions Research Design and Methods Qualitative research: community mapping; key informant interviews; group discussions and in-depth Interviews with women and men Quantitative research: Follow 747 married women (16-25 years) for 2 yrs to assess associations between gender-based power, IPV and health outcomes. Qualitative research: In-depth interviews (n=30) and focus group discussions (n = 13) with women. In-depth interviews (n=30) with primary health care providers.

10. Quantitative Findings:Prevalence & Incidence of Physical IPV • Over half (56%) of participants had ever been hit, kicked or beaten by their husband. • During the 2 year follow-up: • Over half (57%) of those who reported prior experiences of violence continued to do so. • One in five of those who did not report a history of violence at enrollment reported experiencing abuse. • Two fifths of women were employed at study entry, primarily as domestic workers or construction laborers. • Women who were unemployed at one study visit and newly began employment by the next visit had an 80% higher odds of IPV. Source: Rocca et al. 2009 and Krishnan et al. 2010.

11. Quantitative Findings:Triggers of IPV

12. Quantitative Findings:Women’s Responses to IPV Only 1 received support 50% received support

13. Qualitative Findings: Women’s Responses to IPV • Few sought external support partly due to desire to preserve the marriage. • Family members could intervene as IPV viewed as a family matter. • Mothers-in-law were identified as effective supporters of daughters-in-law when their relationship was similar to a mother – daughter relationship.

14. "If there is a problem between husband and wife, [a mother-in-law] can solve it. She can advise me or advise my husband. She can say that this is right or this is wrong as she has the right to do it." Focus group participant, 16-25 years old

15. Qualitative Findings: Physician Leaders as Advocates of IPV Prevention • Subset of physicians (n=12) engaged in actions to mitigate and prevent IPV. • Noted indications of IPV and screened unprompted by patient. • Devised innovative ways to screen for IPV. • Listened actively, believed the patient, and acknowledged her feelings. • Informed patients about IPV law and women’s rights. • Promoted access to community services. • Sought opportunities to improve IPV-related competencies and to influence peer practices Source: Chibber, Krishnan, and Minkler. 2011.

16. A Multilevel Response to IPV

17. Partnerships to End Violence Against Women • Collaborations between employers/corporations and health care/promotion organizations can mitigate IPV and its adverse impacts on health, health care costs, and labor productivity. • Employers/corporations can: • Advocate for investments in prevention of IPV and care for survivors. • Support innovative pilot programs.

18. The Bangalore Team

19. Suneeta Krishnan Senior Researcher 415.848.1320 skrishnan@rti.org More Information